Updated 2022 ASAS-EULAR Recommendations for the Management of Axial Spondyloarthritis

spondyloarthritis, axial spondyloarthritis, SpA, axSpA
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The 2022 ASAS-EULAR recommendations for the management of axial spondyloarthritis were updated to provide guidance for clinicians.
The 2022 updated ASAS-EULAR recommendations provides guidance for clinicians for the management of patients with axial spondyloarthritis.

The Assessment of Spondyloarthritis International Society (ASAS) and European Alliance of Associations for Rheumatology (EULAR) released updated guidelines for the management of axial spondyloarthritis (axSpA). The full recommendations were published in Annals of the Rheumatic Diseases.

The first ASAS-EULAR recommendations for the management of axSpA were released in 2006, with updates made in 2010 and 2016. The 2022 update incorporates new evidence, particularly regarding expanded treatment options.

The EULAR standard operating procedures for guideline development were followed. A steering committee defined research questions and conducted 2 systematic literature reviews. One review focused on pharmacologic and nonpharmacologic treatment and the other addressed biologic disease-modifying antirheumatic drugs (bDMARDs).

A taskforce was convened in February 2022 to review the 2016 ASAS-EULAR recommendations in the context of the literature review and to update the recommendations using consensus (greater than 75% agreement) voting. Level of evidence and strength of recommendation were added to each statement after the meeting. An anonymous online survey was used to obtain level of agreement (LoA), which ranged from 0 (do not agree at all) to 10 (agree fully). A research agenda was identified based on identified gaps in evidence.

It is our vision that these recommendations standardise and optimise the treatment of people living with axSpA, contributing to both individual well-being as well as wider societal benefit through better management of the disease.

The review yielded 5 overarching principles that remained unchanged from the 2016 ASAS-EULAR guidelines and 15 recommendations. Among the recommendations, 8 remained unchanged, 3 received minor edits, 2 were significantly updated, and 2 new recommendations were formulated.

Overarching PrinciplesLoA
The musculoskeletal and extramusculoskeletal manifestations of axSpA are diverse and can be severe, and typically requires multidisciplinary management.9.8
Treatment should aim to maximize long-term health-related quality of life by controlling disease activity (symptoms and inflammation), preventing structural damage, and improving function and social participation.9.8
Management of axSpA can include a combination of pharmaceutical and nonpharmaceutical treatment modalities.9.8
Patients should receive individualized care tailored to their respective case, which can be determined using a shared decision-making approach.9.5
Rheumatologists should consider individual, medical, and societal costs when treating patients with axSpA.9.5
RecommendationChange From 2016 GuidelinesLevel of EvidenceLoA
Patients should receive individualized treatment consistent with their symptoms (axial, peripheral, EMM), comorbidities, psychosocial factors, and other patient characteristics. Diagnosis should be based on clinical presentation and laboratory and imaging tests, not classification criteria.Minor edit to use the term EMM to include uveitis, psoriasis, and inflammatory bowel disease59.6
Disease activity monitoring is essential and should include patient-reported outcomes, clinical findings, and laboratory and imaging tests. The frequency of monitoring should be based on symptoms, severity, and treatment type.No change59.5
A treatment target, defined using shared decision-making, should serve as a guide for care.No change59.0
Patients should receive education about axSpA and the importance of exercise, quitting smoking, and physiotherapy to manage and improve symptoms.Minor edit to use the term physiotherapy instead of physical therapy2b (education, exercise) 5 (stop smoking) 1a (physiotherapy)9.8
NSAIDs are the first-line treatment for patients with pain and stiffness and can be used long-term to control symptoms.Minor edit to specify that the decision to use NSAIDs should not be based on an attempt to slow disease progression.1a9.5
Rheumatologists may consider analgesics, such as paracetamol and opioid-like drugs, after other treatments have failed, are contraindicated, or poorly tolerated.No change, though the relatively low LoA reflects the risk for addiction and lack of proven efficacy of analgesics in axSpA.58.9
Musculoskeletal glucocorticoid injections can be effective for treating local inflammation; however, long-term use of systemic glucocorticoids is not recommended.No change2 (injections) 5 (long-term glucocorticoids)9.6
csDMARDs are not recommended for patients with only axial disease. Sulfasalazine may be considered in patients with peripheral arthritis.No change1a (sulfasalazine, methotrexate) 1b (leflunomide) 4 (other csDMARDs) 1a (sulfasalazine peripheral disease)9.6
If conventional treatment fails, TNFi, IL-17i, or JAKi can be considered. Current practice is to start with TNFi or IL-17i.Updated to reflect current ASAS-EULAR recommendations for the management of axSpA.1a9.2
When treating patients for EMM, there is a preference for anti-TNF monoclonal antibodies over TNFi for uveitis and IBD and IL-17i over TNFi for psoriasis.New2b (uveitis, IBD) 1a (psoriasis)9.1
In the absence of a good response to treatment, rheumatologists should re-evaluate the diagnosis and consider the presence of comorbidities before switching to a different immunosuppressive therapy.New59.5
For patients with an inadequate response to tsDMARD or bDMARDs, switching to another bDMARD (TNFi or IL-17i) or a JAKi can be considered.Updated to reflect expanded treatment options now available.2b (TNFi after TNFi failure) 1b (IL-17i after TNFi failure) 5 (all other switches)9.3
For patients in sustained remission, bDMARD tapering may be considered. Tapering is preferable to withdrawal, which can lead to flares.No change, though evidence is lacking for tapering IL-17i and JAKi1a (TNFi) 5 (IL-17i)9.1
Surgical intervention, including total hip arthroplasty and spinal corrective osteotomy, may be considered for patients with axSpA-related hip or spine problems.No change49.5
A sudden, significant change in the course of the disease should prompt evaluation for causes other than inflammation, such as spinal fracture, especially in patients with ankylosis of the spine.No change59.6

bDMARDs, biologic disease-modifying antirheumatic drugs; csDMARDs, conventional synthetic disease-modifying antirheumatic drugs;  EMM, extramusculoskeletal manifestations; IBD, inflammatory bowel disease; IL-17i, interleukin 17 inhibitors; JAKi, Janus kinase inhibitors; TNF, tumor necrosis factor; TNFi, TNF inhibitor; NSAIDs, nonsteroidal anti-inflammatory drugs; tsDMARDs, targeted synthetic disease-modifying antirheumatic drugs

The research agenda developed by the taskforce included knowledge gaps in assessing, treating, and managing axSpA. Areas that needed additional research included the following:

  • Assessment of disease activity
  • Management of peripheral manifestations
  • Definitions of sustained remission and difficult-to-treat axSpA
  • Biomarkers of prognosis and treatment response
  • Treatment sequences and combinations of drugs
  • Criteria for tapering bDMARDs and tsDMARDs
  • Efficacy and safety of analgesics
  • Safety of TNFi, IL-17i, and JAKi
  • Effects of treatments on EMMs, peripheral manifestations, and disease progression

The taskforce concluded, “The 2022 update of the ASAS-EULAR recommendations provides healthcare professionals taking care of patients with axSpA, patients and other relevant stakeholders with the most up-to- date evidence and expert insights in the management of patients with axSpA… It is our vision that these recommendations [standardize] and [optimize] the treatment of people living with axSpA, contributing to both individual well-being as well as wider societal benefit through better management of the disease.”


Ramiro S, Nikiphorou E, Sepriano A, et al. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Ann Rheum Dis. Published online October 21, 2022. doi:10.1136/ard-2022-223296